THERAPIST ORIENTATION - Premier Pediatric Therapy

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THERAPIST ORIENTATION5038 Champions DriveLufkin, Texas 75901Phone: 832-539-1632Fax: 832-539-1633Office Hours9:00 am - 4:00 pm M-F

TABLE OF CONTENTSTHERAPIST ACCEPTING PATIENTSSUPERVISION FOR SLPADOCUMENTATIONINFECTION CONTROLSAFETYMANDATORY REPORTING OF ABUSE, NEGLECT AND ON OF SOLICITATION OF PATIENTSEMERGENCY PREPAREDNESS RESPONSE PLAN (EPRP)DISCIPLINARY ACTIONPATIENT BILL OF RIGHTS1PremierPediatricTherapy.com

THERAPIST ORIENTATIONAll documentation is computerized. Any patient information on your personal computer or otherelectronic device must be password protected to avoid unplanned disclosure of patient information.Your visits will be scheduled for you on HealthTrust Point of Care, which you will have access to whenwe provide you with a username and temporary password. We will also e-mail you a copy of theinstructional workbook. If needed, you will receive additional instructions regarding set-up and trainingusing HealthTrust Point of Care, but please review the workbook before you input the first routine visit.The workbook will cover how to use both the online and offline versions of the HealthTrust Point of Caresystem, including how to download the Point of Care program to your electronic device. It covers how todocument a visit, make corrections to a failed visit, and much more. If you are having difficulty, feel freeto contact the office for instructional assistance or call HealthTrust Software directly at 877-442-4555 fortechnical assistance.Visits completed on HealthTrust Point of Care include evaluations, re-evaluations, interim progressreports, daily visit notes, missed visits, discharge summaries, and supervision visits. Updates to the planof care goals can also be made on the software.You should obtain parent/caregiver signatures on your Point of Care device. For some tablets, you willneed to use the “Alternate Signature Option” at the bottom of the signature form in order to acquiresignatures. At the end of each visit, accurately document the date, time-in and time-out before askingthe parent/caregiver to sign.Do not give a blank form to the parent/caregiver to sign!!Do not ask parent/caregiver to pre-sign for future visits. Do not sign on behalf of the parent/caregiveras this is considered Medicaid fraud!! Medicaid fraud is taken very seriously at Premier PediatricTherapy, as well as by the State and Federal government. This Agency conducts case conferences withthe parent/caregiver every 3-6 months to validate protocols, quality assurance and customersatisfaction.Do not be tempted to document visits that did not take place. We all worked very hard for our licenseand a loss of license is not worth the cost of one visit rate. Premier Pediatric Therapy will report allconfirmed cased of fraud to the appropriate licensing board and the Office of Inspector General (OIG).Be on time for your appointments. If you are unavoidably delayed more than 10 minutes, please notifythe family. You may also call the office and we will notify the family on your behalf. If you areconsistently late, you may consider adjusting your schedule.2PremierPediatricTherapy.com

ACCEPTING PATIENTSWhen you accept a patient, please understand that this is the beginning of a multi-step process whichmay take 7-30 days to complete. The physician orders must be signed and the patient admission mustbe scheduled and completed. Please do not forget that you have accepted the patient!! We will try tokeep you updated if there are difficulties along the way. You are welcome to inquire about a referralstatus at any time.SUPERVISION FOR SLPANew modality of supervision: "A supervisor may use telehealth for up to four hours of indirectsupervision per month. Additionally, two hours of direct supervision may be done using telehealth. Thismeans the supervisor would be directly observing the assistant provide services using telehealth(something like Skype, Facetime etc)". You can reference TAC Rule 111.211.DOCUMENTATIONEvaluations and re-evaluations are due in the office within 48 hours of completion. All evaluationsreceived more than 5 days late will incur a 5 penalty.Evaluations: For new patients, please contact the families to schedule the evaluation within 48 hours ofreceiving notification from the Therapy Coordinator that the admission has been completed. Delays incompleting the evaluation will delay initiation of treatment for patients that require your services. TheTherapy Coordinator will request that you inform him/her of the scheduled evaluation date to schedulein HealthTrust Software for your completion. If the original scheduled date for evaluation changes,please notify the Therapy Coordinator!Do not make a second visit unless the office has notified you that we have received authorization.Premier Pediatric Therapy does not provide unauthorized care and unauthorized visits will not bereimbursed.Refer to the Evaluation/Re-evaluation Checklist attachment for information regarding the requiredinformation necessary for completion of documentation.Frequency and Duration must be clearly included on the evaluation/reevaluation. For example: 2xweek for 6 months. This frequency and duration must be consistent on the evaluation and CCP form.Remember that this is your recommended treatment for the patient that both the MD and insurancecompany will be considering for approval.Developmental age must be documented on the evaluation/re-evaluation. Please list the specificassessment tools used and the score/results of the tool utilized on the evaluation. Insurance companiesrequire a standardized test be utilized and may deny services when there is not a score, percent ofdelay, and developmental age documented on the evaluation.3PremierPediatricTherapy.com

For OT and PT: If a specific tool does not accurately reflect the child’s developmental age, and there isno other tool to utilize, you must address the specific deficit, why you were unable to accurately reflectthe development age, and how PT or OT services can improve the child’s functional levels.For ST: Please test in patient’s primary language (this will be the language that is used most in thehome). Testing may be performed via translator and must be documented as such. List the specificstandardized tests used and the results of the tests on the evaluation. Consider that insurancecompanies will deny services when there is not a standardized test with scores documented on theevaluation or standard scores 77 or 6 (scores 1.5 standard deviations below the mean).If the standardized test score does not accurately reflect the child’s deficit and there is no other test toolyou can utilize, you must address the specific deficit, why testing was unable to accurately reflect thedeficit and how ST services can improve the child’s functional levels.Short Term goals must be specific, measureable and attainable during a 3-month period. Usually, 4-5short term goals should be written, including a home program goal. (Example: Patient/caregiver will beindependent with Home Program within 3 months. Home Program is updated periodically as necessary.)Please document the specific activities to be performed by the family. Copies of the Home Program areto be turned into the office along with progress notes.Long term goals may be for a year or more, such as “Able to walk independently”, or “Able to makewants and needs known to caregivers.”All plans of care should include the following statement: Patient's home health services may be placedon hold while authorization is being obtained and may resume as soon as authorization is received.Patients may receive up to 3 PRN visits per week when prior scheduled weekly visits are not complete toensure compliance with plan of care. Missed visits will be made up within the cert period but will notexceed the number of visits authorized"The Agency will review your documentation to ensure compliance. You may be called and asked todocument more information on your evaluations and progress notes. Please understand we are onlyresponding to the request of the insurance companies. Please refer to the Evaluation/Re-evaluationChecklist to ensure all required areas are addressed.Re-evaluations: The Agency will send you a friendly reminder when the plan of care or authorization isexpiring and the re-evaluation is due. Ultimately it is your responsibility to know when the certificationand authorization ends and submit paperwork in a timely manner. If you are not sure of theauthorization period, please call the office. Visits completed after the authorization period hasexpired and before a new authorization has been received will be removed from your invoice and willnot be reimbursed. The Agency is not reimbursed for visits that are not authorized.4PremierPediatricTherapy.com

A complete re-evaluation is due every 3-6 months as requested by the office for authorization purposes.You are required to re-evaluate your client 4 weeks before the current authorization expires in order toget the necessary Plan of Care written and signed by the MD in time to request the authorization beforethe old one expires. Some insurance companies require authorization for the reevaluation and there is a30-day window to complete. The Therapy Coordinators will inform you if an authorization is requiredand obtained for your patient’s reevaluation. Please ensure completion and submission of thereevaluations as soon as possible!The reevaluation must have documentation that presents scoring on the same tool for comparison or(medical) explanation why a similar tool or additional tool must be used.If goals are not met, re-authorizations may be denied. When completing re-evaluations, be sure toaddress whether the patient has met their previous goals, and what were the barriers to achieving thesegoals, if the goals were not met. Document baseline functional status, progress made from thebeginning of the treatment period to current service request date. Modify goals if necessary. Short termgoals can be modified at any time during the authorization period. If the patient is not making any orvery little progress, modify the goals and document the reason or justification for the modifications.Please document the Home Program to be administered by the family, including the specific activity tobe performed by the family and parent report of response to the home program.Paperwork not completed and submitted in a timely manner before the authorization ends willrequire a ‘HOLD” in services. Premier Pediatric Therapy does not provide unauthorized care. A signedMD order and Insurance Authorization must be in place prior to any visit being made.Upon reevaluation, encourage the parent to make an appointment with the patient’s physician todiscuss the need for continued therapy, if the child has not been seen by the MD in the past 6 – 12months. Some insurance companies require that the request for authorizations be submitted directlyfrom the MDs office. If the patient has not been seen by the MD, the MD may refuse to sign the Plan ofCare.Reevaluations are completed every 6 months or more often as requested by the insurance companiesfor authorization purposes. The process is: Initial Evaluation Interim Progress Report or Re-Evaluationafter 3 months of treatment Reevaluation to be completed at the 5-month mark, and so on.60 Day Progress Report: (PTs ONLY): Physical therapists are required to complete a 60 Day progressreport and the progress of achievement toward each goal is to be documented. When a client reaches85-90% mastery of the goal, that goal may be discontinued and a new goal added if necessary.Interim Progress Reports: (Due any insurances): This report is due every (3) months and should reflectthe current goals that are being addressed during a treatment session. If the goals have been met, youmust update the goals on the interim and on your progress note.5PremierPediatricTherapy.com

If the goal has not been met, please reflect the baseline, the progress made toward the goal, and thebarriers to goal attainment. For example: Patient will appropriately answer yes/no questions 50% of thetime without cuing – Goal not met, however patient has improved from 10% to 30% during thiscertification period and has the potential to meet this goal with continued ST intervention.Progress Notes: You are encouraged to document and sync your notes daily. This reduces the stress onthe billing department and allows time for failed notes to be corrected and synchronized prior to thedeadline. All documentation received more than 14 days late will be paid at a reduced rate of 12.00per visit per patient. It is not our desire to decrease your pay, but we need documentation on time asdocumentation submitted late creates a backlog in the office. By State regulation, notes must be in thepatients’ chart within 14 days of service. A decrease in pay rate is used only to discourage latesubmission.Treatment visits should last approximately 30 minutes. While we understand there are sometimesmitigating circumstances, therapy lasting less than 30 minutes must have documentation showing thereason for the reduced session. If the patient is unable to tolerate the full session, there should be agoal that addresses the patient’s increased tolerance/endurance of therapy session.Please document any illness or infections the patient has had since your last visit, including the date ofillness, and any medication changes. (List Name of Drug, Mg/ml amount to be given, frequency androute. Ex: Tylenol 80 mg/ml 2 ml by mouth 4-6 hours as needed as written on the prescription label).Daily progress notes should reflect the S.O.A.P note format. Your treatment must address your goals. Ifit does not, please document why. It is not necessary to address every goal every session, it is necessaryto state that the goal was not addressed that session and why. Documentation of progress made eachvisit towards current goals is very important. Please review the Progress Note Checklist for theinformation that is required (updated 2017). Ensure your documentation addresses the home exerciseprogram. Insurance companies are requesting copies of the home exercise program as well asdocumentation of the parent participation, and denying services if the Agency is out of compliance.Documentation must be detailed and include specific activities performed during the sessionMissed Visits: Medicaid authorizes the number of visits per certification period. If a therapy visit ismissed one week, the visit MAY be made up the following week, but be sure to notify the office of yourintentions to make up the missed visit. Make sure you do not exceed the total visits authorized in anauthorization period as these visits will not be reimbursed. Missed visits should include the date andrationale for the missed appointment in order to be considered complete documentation.Patients may be seen only once per day for the same service. A make-up visit must be completed on adifferent day. For example, if a patient is authorized for 2 visits per week and you only complete 1 visitthat week, the patient may be seen for 3 visits the following week.You may NOT provide an extended treatment session to make-up for a treatment that was missed.6PremierPediatricTherapy.com

Always call the office prior to scheduling a makeup visit to ensure the visits are authorized and available.If there are no available visits on your schedule for that particular week, please call the office so thevisits can be added. Do not use visits from previous weeks or future weeks!Missed visits are not reimbursed. If you have a family that frequently no-shows, be sure to call beforeyou go. Also, call the office if there are 3 consecutive no-shows (where patient is not home forscheduled visit). The Therapy Coordinator will contact the parent and determine if the parent isinterested in continuing the therapy. Visits made when patient not home are not reimbursed. Also,attempted visits are not reimbursed.Too many missed visits can and will be frowned upon by the agency and the payer. The child cannotmake progress and meet the established goals if there are too many missed visits. Insurance companiesare requesting documentation of the patient’s attendance and reason for missed appointments whenconsidering continuation authorizations. We do not want services to be denied because of cancelledvisits by therapists. Payers are denying treatment authorizations due to lack of progress or very littleprogress made. If the child is not consistently receiving treatments it is likely that the child will notachieve the established goals.Report to PPT any hospitalization or ER visits as soon as you become aware. PPT must send HOLDorders to the MD when the patient has been hospitalized. The Therapy Coordinators will request thatyou assist them with some key information to include on the hold order; such as name of the hospital,date of hospitalization, and reason. If you don’t tell us, most times we don’t know. If the child washospitalized overnight (unless just for testing) a reassessment may need to be completed by thesupervising therapist upon discharge from the hospital. The patient will need a reassessment only ifthere is a change in condition or functional status; the reassessment should include new goals,precautions, and etc.INFECTION CONTROLIt is our policy to address infection control, including the prevention of the spread of infectious andcommunicable diseases. All clinical staff must document any infections the patient acquires whilereceiving services from the Agency. Infection reports must include the date the infection was detected,patient’s name, primary diagnosis, signs and symptoms, type of infection, pathogens identified, andtreatment as disclosed by the parent/caregiver. Remember to ask parents/caregiver if any recentinfections and/or new antibiotics, and whether the MD has or needs to be notified. Report any of theseinfections as soon as possible to the office.Hand washing is the single best way to prevent infection. Wash your hands when entering a client’shome and when leaving. Hand gel or Anti-bacterial wipes are a viable alternative.Equipment taken from patient to patient must be wiped down with Clorox wipes or other appropriatecleaners between each patient. When treatment is provided while the patient is on the floor, utilize a7PremierPediatricTherapy.com

barrier such as a blanket, mat, plastic, etc. Also, ensure placement of a barrier between your personalitems and the supporting surface.Utilize Personal Protective Equipment, whenever necessary. Contact the office if you need PersonalProtective Equipment.SAFETYAlways be aware of your surroundings when walking from your vehicle to the patient’s home. If youever find yourself in a scenario where you feel unsafe, please notify the office. We do not want you toprovide services in an environment where you or fellow therapists feel unsafe.MANDATORY REPORTING OF ABUSE, NEGLECT AND EXPLOITATIONEach therapist is required by their licensing board and by federal regulation to report all cases of abuse,neglect, and/or exploitation. If you suspect this may be occurring, document your findings, immediatelyinform the Agency, and report the incident to the Texas Department of Family and Protective Services.COMPLAINTSThe Agency must investigate all complaints by patient’s parents, caregivers or healthcare providersregarding any treatment or care that was furnished by the agency; treatment or care that the agencyfailed to furnish; or lack of respect for the patients’ property by anyone furnishing services on behalf ofthe agency.Therefore, it is critical you become aware of some of the major complaints this past year –1. Lack of communication between therapist and parents2. Discontinuation of treatment by the therapist without notification when goals are met.3. Therapist behavior with patients.4. Number of Missed Visits (too many cancellations by therapist)You must communicate with the parent/caregiver regarding the progress and goals at all times. Parentsshould be notified when the goals are met and when discharge will occur; the supervising or treatingtherapist is the first to know if goals are met and must notify parents/caregivers of pending discharge.INCIDENTS/ACCIDENTSThe Agency’s procedure for reporting patient incidents and accidents states that the employee orcontractor (if applicable) discovering the occurrence will notify his/her supervisor as soon as possible.The supervisor will assist the employee or contractor (if applicable) in completing an Incident ReportForm and forward the form as soon as possible to the Administrator/Alt. Administrator.In all cases, patient safety comes first. The therapist will notify the patient’s physician as indicated orneeded, coordinate any action and follow up to assure the patient’s safety.8PremierPediatricTherapy.com

If you suspect abuse, neglect, or exploitation, you are required to report it CPS within 24 hours1. CPS Phone Number: 1-800-252-5400 and provide them the following information:a. Patient’s full name and date of birthb. Patient’s address and telephone numberc. Date and details of suspected abuse, neglect, or exploitation2. Complete the visit within HealthTrust Software Point of Care and create an incident with thefollowing information included:a. Date, time, and reference number of the CPS reportb. Information CPS provided to youc. Description of suspected abuse, neglect, or exploitationPROHIBITION OF SOLICITATION OF PATIENTSAll practices which would be construed as patient referral solicitation are prohibited. Allstaff/contractors shall bring to the immediate attention of the Administrator or Alt. Administrator anyact related to illegal remuneration or solicitation of patients. Caregivers will be informed of their right toutilize the healthcare provider of their choice. Violation of the policy, or conduct for illegal remunerationfor patient referral can result in termination of employment and contractual arrangement.EMERGENCY PREPAREDNESS RESPONSE PLAN (EPRP)The employee/contractor should be the person most concerned for his/her own safety during a disaster.In addition, all employees/contractors have certain duties to assure the safety of other staff members,patients and caregivers. These include:1. Knowing their job and always applying safe work practices.2. Recognizing the hazards of the job and taking precautions to assure safety to themselves andothers.3. Informing their supervisor of hazards and recommending how to eliminate them, or how toimprove EPRP performance.4. Actively participating and cooperating in the overall EPRP program.5. Appropriately utilizing and maintaining equipment as related to disaster planning.6. Preventing injury to themselves and to others.7. Participating in performance improvement and quality control activities related to EPRPmanagement as indicated.8. Educating others regarding EPRP practices.9. Participate in mitigation/recovery phase of Emergency. In the event of a pendingdisaster/emergency, the therapist will be asked to contact certain of their clients (client may bebeing seen by more than one therapist) to obtain up to date information regarding the family’splan to survive the disaster. The therapist will be given specific instructions as to the9PremierPediatricTherapy.com

information to obtain from the family.The therapist will be given a list of phone and cell phone numbers where he/she may be able to reachagency personnel.Therapists may choose to evacuate the area. The agency should be notified as soon as possible, if that isthe plan. When the therapist is able to communicate with agency personnel, contact should be made assoon as possible.The following information may be requested from the family:1. Are you aware of the pending emergency?2. What plans have you made to endure it?3. Are you planning to evacuate? Where will you be? Can you be reached by phone there?4. If you are not evacuating, do you have at least a two-week supply of medications available foryour child?5. Is your child dependent on electricity? If so, do you have a back-up generator and a largegasoline supply?6. If the child is dependent on electricity, the family should make arrangements to go to a hotel orother facility that has back up power supply.7. Instruct the family to contact the therapist and/or the agency as soon as they can reachsomeone so we can tell when they are available for therapy again.8. Provide the family with a list of phone numbers they can attempt to contact after theemergency.Therapist’s responsibilities following Emergency/Disaster situation:1. Therapist is to communicate with agency as soon as he/she is able following an Emergency.2. Therapist may begin seeing patients at the earliest availability of the patient and therapist,following a break in service due to a Disaster/Emergency, as long as it is within the dates of thecurrent authorization.10PremierPediatricTherapy.com

DISCIPLINARY ACTIONConfidential Medical Peer Review Privileged Quality Improvement ProcedurePOLICYDiscipline of PPT employee/contractors for inappropriate behavior is imposed in a fair and consistentmanner to ensure the competency of Premier Pediatric Therapy employees/contractors.Inappropriate Behavior is defined as actions that adversely affect the quality of care, personal safety orcomfort of clients or the proper functioning of Premier Pediatric Therapy operations, services, programs,activities and staff.PROCEDURE1.Inappropriate behavior demonstrated by a Premier Pediatric Therapy employee or contractor isreported to the Administrator or her designee in his or her capacity as an agent of the QualityReview Committee and documented.2. The Administrator or her designee, acting as an agent of the Quality Review Committee:a. Investigates the report of inappropriate behavior to determine validity.b. Reviews and discusses the issue with another member of the Quality ReviewCommittee.c. Communicates with the employee/contractor who reportedly demonstrated theinappropriate behavior.3. In the communicating with the employee/contractor who reportedly demonstrated theinappropriate behavior, the Administrator or her designee:a. Considers the following courses of action with regard to the staff member’s reportedinappropriate behavior.i. A verbal warningii. A written warningiii. A suspension noticeiv. A termination noticeb. Discusses the inappropriate behavior with the employee/contractor. Encourages theemployee/contractor’s input in writing regarding the incident.c. Clarifies relevant issues or problems from management perspective.d. Notes desired corrective action to be taken within a defined period.e. Notes the possibility of further disciplinary action if such corrective action is not taken inthe stipulated time period.f. Notes that all documentation regarding the inappropriate behavior will be place in theemployee/contractor’s peer review file.g. Completes the Disciplinary Action Form and requests that the employee sign the report.11PremierPediatricTherapy.com

4. The Administrator or her designee subsequently:a. Documents the meeting with the employee/contractor on a Quality Review CommitteeEmployee Counseling Statement.b. Arranges follow-up meetings, as appropriate with the staff member to assess programswith the plan of corrective action.c. Documents subsequent meetings with the staff member on the Employee CounselingFollow-up form.5. If the corrective action is not taken by the Premier Pediatric Therapy employee/contractorwithin the defined time period, or if the employee/contractor demonstrates furtherinappropriate behavior, the Administrator or her designee, acting as an agent of the QualityReview Committee:a. Implements the next steps of the disciplinary process as noted in the previous meetingregarding this behavior.b. Documents the next step of the disciplinary process on the Employee Counseling form.c. Gives a copy of the Employee Counseling Follow-up form describing the next step of thedisciplinary process to the Premier Pediatric Therapy employee /contractor.6. Premier Pediatric Therapy employees/contractors may be terminated immediately forinappropriate behavior if the Administrator determines this is an appropriate course of action.Premier Pediatric Therapy shall be the SOLE judge of the competency of any employee/contractor, andmay discharge ANY employee/contractor with or without cause, and without notice. Theemployee/contractor may also resign at any time with or without cause.12PremierPediatricTherapy.com

PATIENT BILL OF RIGHTSPPT clients and their legal guardians or parents have the right:1. To be informed in advance of the care to be furnished, the plan of care, the expected outcomes, barriers to treatmentand any changes in the care to be furnished.2. To participate in the planning of the care or treatment and in planning changes in the care or treatment.3. To be advised or consulted with, in advance of any change in the plan of care.4. To refuse care and services.5. To be informed, before care is initiated, of the extent to which payment may be expected from the client, third-partypayers and any other source of funding known to the agency.6. To have assistance in understanding and exercising their rights.7. To exercise their rights as a client of Premier Pediatric Therapy.8. To have their person and property treated with consideration, respect and full recognition of their individuality andpersonal needs.9. To confidential treatment of their personal and medical records except as authorized by them.10. To voice grievances regarding treatment or care that is, or fails to be, furnished or regarding the lack of respect forproperty by anyone furnishing services on behalf of the agency without fear of discrimination or reprisal for doing so.11. To have their rights as a minor (under age 18) exer

SUPERVISION FOR SLPA New modality of supervision: "A supervisor may use telehealth for up to four hours of indirect supervision per month. Additionally, two hours of direct supervision may be done using telehealth. . on hold while authoriz

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